Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
Renal Foot Care
Christian Pankhurst
• The consequences of poor management of the renal foot are
considerable: prolonged ulceration and ill health, gangrene and
amputation, depression and death. The health complications are
increased with the added complication of co-morbidities, such as
diabetes.
• Good management requires close coordination between different
health care professions – such coordination is not yet widespread.
Reorganisation needs to be implemented to improve health
outcomes and reduce costs.
• Dialysis treatment has been independently associated with foot
ulceration. The risk factors contributing to foot ulceration in the
diabetic population are well published. Most studies and papers
available present diabetic patients with kidney disease,
demonstrating the acceleration of risk factors in association with
diabetic nephropathy, with a consistent message of increased risk of
foot ulceration and lower limb complications.
Screening the Renal Foot
• Although there is no general agreement on the
definition of renal foot, the ‘renal foot’ is a colloquial
term often used to refer to patients with stage 4/5
kidney disease. There are 5 divisions of renal failure
according to a patient’s glomerular filtration rate
(GFR), with patients requiring dialysis who are classed
at level 4 or 5.
• The ‘Renal Foot’ is seen as being:
– Hypoxic
– Malnourished
– Complex metabolic changes lead to cachexia,
immune paresis & anaemia
– Charcot is associated with nephropathy
• According to the spectrum, basic foot screening
should follow the same principles as those for diabetic
patients
• Regardless if the renal patient has a coexisting
diagnosis of diabetes or not - It is important to
consider that calcification of the vessels applies to
diabetic patients and well as non-diabetic patients,
with neuropathy also occurring in renal patients due to
uraemia
• Carrying out the foot check including the above list
would place the patient within a particular risk category
(much as NICE recommends for diabetic patients).
• A patient on dialysis attends hospital 3 times a week
for 4-5 hours (156 hospital visits per year), during
which time they will be resting their vulnerable feet
against a vinyl couch and be relatively immobile,
putting them at increased risk of pressure sores
• Patients diagnosed with stage 4/5 renal failure should
automatically be considered as being High risk of
developing foot complications
• It is generally considered that all renal patients on
dialysis will have neuropathy to some degree (due to
uraemia), however it is always good practice to check
for this and document it.
• When screening a patient, once neuropathy or
ischaemia has been documented, the need to
continue to screen for this would not be necessary all
of the time as this is not likely to improve, however
INSPECTION IS CRUCIAL AT ALL VISITS.
• Literature suggests that patients with renal
complications are more prone to Charcot
Osteoarthropathy (COA). Therefore, patients should
always be screened for swelling, heat and any
deformity about the foot/ankle complexes
• Due to the amount a healthcare professional is
required to do for patients on dialysis, a quick, easily
repeatable foot check is required with a single point of
referral in case of any concerns
• This should happen at the start of dialysis treatment in
order to have time to alert the necessary people for a
more detailed examination and any subsequent
treatment during the time a patient is undergoing
dialysis
• If infection is suspected, bloods should be sent for
inflammatory markers (including CRP) at the
beginning of dialysis. That way, if any IV antibiotics are
required to be administered, these can be given
through the dialysis line/portal within good time while
dialysis is running
• Patients with any diagnosis of renal failure will need to
be regularly screened. This includes those who have
had renal transplants
• There is a low threshold for error and securing help
with complications of the renal foot. Help should
always be sought if any new swelling, redness, heat,
discolouration, lesions or ulcers are noted
Assessment • For every patient in dialysis, a foot check should be
carried out before and after the treatment.
• Each foot check will only take a few minutes to
perform.
• Patients need to keep an eye on their feet at home
and during their time on dialysis, therefore it is
essential to ensure that patients receive a quality foot
check from a properly trained person at every
appointment and reiteration of foot care advice.
• The risk status of the patient on dialysis should
automatically be considered as being High, in the
absence of any active foot problems, with a referral for
specialist expert advice and treatment if an active
problem is discovered during the examination.
• History of foot problems
• Neuropathy
• Ischaemia
• Deformity
• Swelling/Oedema
• Lesions/Infection/Ulcers/Cracks or breaks
in the skin
• Discrete areas of necrosis
• Discolouration
• Motor power
Check, Protect, Refer (CPR)
• The renal and dialysis service should institute
standardised foot care CPR for all patients
admitted to the renal service.
• Check
When a patient is referred admitted to the team their
feet should be checked for:
– History of foot problems (ulcers or toe/foot pain)
– Neuropathy – Touch toes test / monofilament
– Ischaemia – Pulse check
– Deformity - Inspection
– Swelling/Oedema - Inspection
Sessional foot checks should involve the
following:
Patients should be asked to remove any footwear and
socks/stockings.
– Their feet should be examined – including looking for corns,
calluses and changes in shape.
– Feet should be tested for numbness or changes in sensation
(‘neuropathy’) with a fine plastic strand called a monofilament
or a tuning fork.
– Lesions/Infection/Ulcers/Cracks or breaks in the skin (especially
cracks between the toes which present as seemingly dry breaks
in the skin which are often initially small and are not usually
infected immediately)
– Discolouration – indicating the development of severe ischaemia
/ infection
– Discrete areas of necrosis
– Motor power – motor/focal neuropathy (e.g. foot drop)
Questions should be asked about the patient’s feet and
the management of any coexisting medical
complication (e.g. diabetes), including:
• Has the patient noticed any problems or changes (e.g.
cuts, blisters, broken skin or corns)?
• Has the patient had any previous foot problems or
wounds?
• Has the patient experienced any pain or discomfort?
• How often does the patient check their own feet, and
what do they look for?
• Has the patient had any cramp-like pains when walking?
• How well is the patient managing any coexisting
medical complications (e.g. diabetes)?
• Footwear should also be examined to make sure it is
not causing any problems to the feet.
• At the end of the foot check, patients should be told
the results and be provided with education regarding
their risk of foot problems (verbally and written).
From the ‘Ipswich Touch Test’ designed by Dr G Rayman and Team from Ipswich Hospital. With the kind permission of
Diabetes UK
• Protect – If a patient has had a previous foot
problem or is at risk of developing a foot problem care
should be taken to protect the patient’s feet.
• Refer – Patients who have a current foot ulcer and
those at high risk of developing a foot ulcer should be
referred to the local podiatry or orthotic service. The
renal and dialysis service should work the local
podiatry services, foot protection teams and foot care
MDTs to develop a single point of referral for renal and
dialysis patients to access more specialist foot care if
needed.
Information should include:
• Advice about how to care for the feet –
according to the level of risk
• An agreed management/treatment plan
• Emergency contact details
• Immediate referral to a multi-disciplinary foot
team when appropriate
• Renal and dialysis services should have a
named health care professional responsible for
improving access to foot checks and improving
quality of foot health for renal patients (‘Foot
Champion’).
Outcome Measures:
• Reduce the complications of microvascular
disease
• Improve secondary prevention
Information for patients:
• All patients should be encouraged to carry
out a daily inspection to look out for…
Damage to the nerves which might be indicated by:
– tingling sensation; pins and needles
– pain (burning) - feet that are red and hot to touch
– sweating less - changes to the shape of the feet
– hard skin - loss of feeling in the feet/legs.
Damage to the blood supply which might be
indicated by:
– cramp in the calves (at rest or when walking)
– shiny smooth skin - loss of hair on the legs and feet
– cold, pale feet - changes in the skin colour of the feet
– pain in the foot/feet - swollen feet.
– wounds or sores that do not heal
• If any of these are noticed, or patients
have concerns about their feet, advice
to make emergency contact with the
multi-disciplinary foot care team should
be given.
Documentation
“After I’ve been screened and put into
one of the risk categories…what then?!”
For Diabetic Patients, it was found that where the Putting
Feet First campaign strives to ensure consistency,
transparency and a reduction of inter-practice variability
with foot screening, Patients were concerned that there is a
lack of the above points when it comes to the resulting
advice and information provided and, indeed, how this was
passed on to individuals.
Patients were concerned of a lack of information provided
following this stratification/screening algorithm.
• Patients were wanting to be provided with information that affected them in their current state and advice to prevent deterioration and “...be provided with the right information at the right time”
• Patients and clinicians wanted information which was: – Reflective of the outcome of the foot screening
– Reliable
– Valid
– Relevant
– Assured
– Accurate and Up-to-date
– Clear and easy to read
• Patients also advised that the information
provided needed to be:
– Consistent throughout the country, no matter
who is performing the screening
– Endorsed by trusted, reliable and recognised
organisations
Patient Information
• During discussions, the views of the
patients echoed those concerns raised by
clinicians, in that comprehensive,
regulated foot services are needed where
everyone, everywhere gets the same
standard of care and information.
Process • A review of all available patient information literature was
conducted
• A review of the screening processes employed was also
conducted
• New questions were asked of renal patients both with
and without a history of active foot problems and patient
groups
• These questions were also asked to Health Care
Professionals involved in the management of diabetic
patients
• A review of available information from across the
country, taking patient and clinician/practitioner views
and comments in to consideration
Documentation Formulated
Draft patient information leaflets include:
• Foot care/ protection during dialysis
• Low risk
• Moderate risk
• High risk
• Infected foot
• COA
• Footwear
• Holiday feet
Action
• With consent, the leaflets were reviewed
locally before being put forward to local
patients, patient groups and practitioners
• Feedback received included: - Very good - Inform patients of their risk
- Look good - Excellent leaflets
- Simple and consistent - Easily readable
- Straight forward - Patient friendly
Action (continued…)
• Patients canvassed expressed concerns:
– Information being accessible and available to
patients across the country
– Reminded of the previously raised point of
trying to obtain endorsement/recognition of
recognised and trusted bodies to obtain
patient confidence, trust and belief in the
information given
The following Societies are
currently reviewing the literature:
• The Renal Association
• National Kidney Federation
• British Kidney Patient Association
• Scottish Kidney Federation
• British Renal Society
• Kidney Wales Foundation
• Royal College of Nursing
• College of Podiatry
• British Association of Prosthetists and Orthotists
A best practice document has been drawn up
which includes the following: – Key themes
– Introduction – why is there the problem
– Scale of the problem
– Explain pathology and progression
– Patient empowerment
– Case for change – coalition of services vs current state of play
– 5 processes of care
– Patient education
– Preventable risk of amputation
– Patient should have their foot risk assessed by a knowledgeable
professional
Such a document will need to be peer reviewed
in order to discover and disseminate best
practice from various units, citing centres of
excellence of foot care.
Feedback
• Please send all comments and feedback
regarding the leaflets and screening tool
to:
Thank You